Hematuria overview

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Differentiating Hematuria from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

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Diagnostic Evaluation

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Physical Examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Steven C. Campbell, M.D., Ph.D.Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2] Aida Javanbakht, M.D.

Overview

Presence of >5 red blood cells (RBCs) per high-power microscopic field in the urine is called hematuria. It can have either benign or malignant etiology. Patients with hematuria could be asymptomatic. Therefore, all patients presenting with a single episode of haematuria require urgent investigation. Microscopic hematuria, or microhematuria (MH), is defined as the presence of RBC on microscopic examination of the urine not evident on visual inspection of the urine. The prevalence of MH among healthy participants in screening studies is 6.5% (95% confidence interval [CI] 3.4 to 12.2), with higher rates in studies with a predominance of males, older patients, and smokers.

Definition

Presence of >5 RBC per high-power microscopic field in the urine is called hematuria. [1] Three samples are needed and samples should be taken in a week interval. Urinary dipstick it lacks specificity for MH as it also detects myoglobin and free heme without the presence of any hematuria.[2]

Classification

Hematuria may be classified based on its source, visibility, duration and pathophysiology.

classification by its source Classification by the visibility Classification by the duration of hematuria Classification by Pathophysiology
  • Extrarenal hematuria
  • Nonglomerular renal hematuria
  • Glomerular hematuria
  • Visible hematuria
  • Non-Visible hematuria
  • Transient hematuria
  • Persistent or Significant hematuria
  • Glomerular hematuria
  • Non-glomerular renal hematuria
  • Upper urinary tract
  • Lower urinary Tract

Causes

Causes of hematuria can range from benign conditions such as urinary tract infection to serious conditions such as bladder cancer.[3] Extrarenal site is responsible for more than 60% of cases of hematuria. Of these, the most important underlying disease is malignancy. In the primary care population, about 5% of patients with microscopic hematuria will have a urinary tract malignancy, mainly of the bladder or prostate. The most common nonmalignant causes of extrarenal hematuria are infections, such as cystitis, prostatitis, and urethritis.Regarding renal causes of microscopic hematuria, the most common cause of isolated glomerular hematuria (without significant proteinuria) is IgA nephropathy, followed by thin basement membrane disease, hereditary nephritis (Alport syndrome), and mild focal glomerulonephritis of other causes.[4]


Resolvable or self-limited causes[5]:

  • Strenuous exercise
  • Fever
  • Medications
  • Exposure to toxins, such as contrast dyes used in radiological procedures
  • Physical injury to the kidney or bladder
  • Menstrual or gynecological bleeding


Differential Diagnosis

Differential diagnosis of hematuria are wide. False-positive hematuria like myoglobinuria should be rule out first. Also, for distinguishing hematuria from vaginal bleeding, it is recomended to not taking sample during menstrual or gynecologic bleeding, or, in emergency cases,sample should be taken by a catheter.

Epidemiology and Demographics

Asymptomatic hematuria is common in clinical practice, with a prevalence ranging from 0.18% to 38.7%.[6] Transient microscopic hematuria may occur in 6% to 39% of the population studied, but persistent microscopic hematuria in 3 or more consecutive urinalyses occurs less often, and is seen in 0.5% to 2% of the population under study. In the prevalence of underlying urinary tract disease, there is no clear difference between patients with transient microscopic hematuria and those with persistent microscopic hematuria.[7]

Risk Factors

Common risk factors for urinary tract malignancy in patients with hematuria[8]:

  • Age older than 35 years
  • Analgesic abuse
  • Exposure to chemicals or dyes (benzenes or aromatic amines)
  • Male sex
  • Past or current smoking
  • History of any of the following:
  • Chronic indwelling foreign body
  • Chronic urinary tract infection
  • Exposure to known carcinogenic agents or alkylating chemotherapeutic agents
  • Gross hematuria
  • Irritative voiding symptoms
  • Pelvic irradiation
  • Urologic disorder or disease

Natural History, Complications and Prognosis

Natural history, complications and prognosis of hematuria and microscopic hematuria depends on the severity of the disease. Finding the cause is the main factor which determines the prognosis. As hematuria has a vast majority of causes the complications depends on the specific etiology.The rate of malignancy detected among patients evaluated for a single positive urinalysis was 3.6%. Thus the most recent AUA guideline panel has determined that a single positive urinalysis is sufficient to prompt evaluation.[9]

Diagnosis

History and Symptoms

History and symptoms of hematuria depends on the eitology. The history should also include an assessment of associated symptoms, such as gross hematuria, voiding symptoms, or flank pain. Patients' risk factors for known causes of hematuria also should be queried. It is important to know the patient's urologic history, particularly any surgeries or febrile UTIs. It is also critical to ask about the patient's general medical history, to identify potentially contributory diagnoses, such as hypertension, renal insufficiency, bleeding disorders, or sickle cell disease. Current medication use, including anticoagulants and antiplatelet therapies, should be elicited, along with recent coagulation values and any concomitant medications that would potentiate the effects of blood thinners. Family history of nephritis, polycystic kidneys, and rare familial tumor syndromes of the kidney (e.g., von Hippel-Lindau) or urothelium (e.g., Lynch syndrome) also may be informative.[10]

Physical Examination

Physical examination of the patient with MH should be focused on isolating the underlying cause. The physical examination findings will vary depending on the etiology, as follows:[1][2]

  • Blood pressure, heart rate, respiration rate, temperature, and consciousness level are important to assess hemodynamic stability, volume status, and possible presence of shock or sepsis as the treatment of hematuria is driven by the underlying pathophysiology and is in large part conservative.
  • Presence of hypertension may indicate advanced glomerulopathy.
  • Skin and mucosal membrane examination are useful to check for signs of bleeding disorders, such as petechiae, purpura, ecchymoses, and gingival bleeding.
  • Jugular venous distention indicates volume overload.
  • Flank tenderness;
  • Masses in the flank, abdomen, suprapubic area, or urethra
  • Enlarged, nodular, tender, or fluctuant prostate.
  • Bruising
  • Fever

Diagnostic Evaluation

Specifically, among patients with GH, 50% have been found to have a demonstrable cause, with 20% to 25% found to have a urologic malignancy, most commonly bladder cancer and kidney cancer. Given the increased frequency with which clinically significant findings are associated with GH, the recommended evaluation in this setting is relatively uniform. That is, patients presenting with GH in the absence of antecedent trauma or culture-documented UTI should be evaluated with a urine cytologic examination, cystoscopy, and upper tract imaging, preferably CT urogram. <figure-inline class="mw-default-size"><figure-inline><figure-inline>Evaluation of Microscopic Hematuria Algorithm.jpg</figure-inline></figure-inline></figure-inline>

Treatment

Medical Therapy

Treatment depends on the etiology of the hematuria and severity of symptoms. Controlling high blood pressure is usually the most important part of treatment.

Medicines that may be prescribed include:

  • Blood pressure medications to control high blood pressure, most commonly angiotensin-converting enzyme inhibitors and angiotensin receptor blockers
  • Corticosteroids
  • Medications that suppress the immune system

Surgery

Surgery for hematuria depends on the underlying etiology.

Prevention

There is no specific preventive methods for either hematuria or microscopic hematuria.

References

  1. 1.0 1.1 Cohen RA, Brown RS (2003) Clinical practice. Microscopic hematuria. N Engl J Med 348 (23):2330-8. DOI:10.1056/NEJMcp012694 PMID: 12788998
  2. 2.0 2.1 Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ et al. (2012) Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol 188 (6 Suppl):2473-81. DOI:10.1016/j.juro.2012.09.078 PMID: 23098784
  3. Rew, Karl (2010). Primary care urology. Philadelphia, Pa. London: Saunders. ISBN 978-1437724899.
  4. Rew, Karl (2010). Primary care urology. Philadelphia, Pa. London: Saunders. ISBN 978-1437724899.
  5. Blood in Urine (Hematuria). American Association for Clinical Chemistry (2020). Available at https://labtestsonline.org/conditions/blood-urine-hematuria. Accessed on April 14, 2020
  6. Loo RK, Lieberman SF, Slezak JM, Landa HM, Mariani AJ, Nicolaisen G et al. (2013) Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria. Mayo Clin Proc 88 (2):129-38. DOI:10.1016/j.mayocp.2012.10.004 PMID: 23312369
  7. Rew, Karl (2010). Primary care urology. Philadelphia, Pa. London: Saunders. ISBN 978-1437724899.
  8. Sharp VJ, Barnes KT, Erickson BA (2013) Assessment of asymptomatic microscopic hematuria in adults. Am Fam Physician 88 (11):747-54. PMID: 24364522
  9. Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ et al. (2012) Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol 188 (6 Suppl):2473-81. DOI:10.1016/j.juro.2012.09.078 PMID: 23098784
  10. Wein, Alan (2016). Campbell-Walsh urology. Philadelphia, PA: Elsevier. ISBN 978-1455775675.

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